tbuckley/cabot-search huggingface dataset:
Continued outpatient oncology care for cancer survivors by antineoplastic medication use: Identifying opportunities for stratified survivorship care.
Authors: Sarah A Birken, Alexandra Peluso, Cheyenne Wagi, David I Shalowitz, Scott Isom, Ronny A. Bell, Carla Strom, Ajay Dharod, Richa Bundy, Kathryn E. Weaver
Journal: Journal of Clinical Oncology (2022)

226 Background: Cancer survivors may be more likely to receive preventive care services when they see both oncologists and PCPs; however, some oncology visits may not be necessary, straining limited subspecialty resources. In this study, we quantified outpatient primary and oncology care utilization in the years surrounding cancer diagnosis. We further characterized the proportion of survivors with oncology visits in the absence of ongoing antineoplastic use, as we hypothesized these survivors might be appropriate for need- and risk-stratified survivorship care, a model successful outside the US. Methods: We conducted a retrospective review of the electronic health records of survivors in an academic health center diagnosed with breast, colorectal, or uterine cancer between 1/1/14 and 9/1/19. We excluded survivors who died during the study period, had a PCP outside of our health system, or had recurrent cancers. Descriptive statistics described survivors’ provider visits up to 4 years before and 8 years after diagnosis with their most recent cancer. We then stratified our results by current antineoplastic prescription. Results: Our sample included 1,929 survivors (75.0% white, 20.1% Black, 5.0% other; 86.2% female; cancer type: 59.4% breast, 26.7% colorectal, 13.8% uterine). In the first-year post-diagnosis, 94.6% of survivors had an oncology provider visit; the figure declined to 55.8% by year 8. The percentage of survivors with PCP visits increased from 41% 3-4 years pre-diagnosis to 66% in year 1 and remained at &gt; 50% 8 years post-diagnosis. More than 50% of survivors saw both PCPs and oncologists through 5 years post-diagnosis. Survivors were slightly more likely to have an oncology visit if they were on antineoplastics; 5+ years after diagnosis, &gt;50% of survivors not on antineoplastics had oncology visits. Conclusions: A slight majority of 5+ year survivors, regardless of antineoplastic use, continue to have oncology visits and may be candidates for discontinuing oncology care. Work is needed to develop and test interventions to facilitate need- and risk-stratified survivorship care focused on transitioning longer-term survivors not on antineoplastics to PCPs.
Carbon emissions and non-biodegradable medical waste generation with alternative dosing strategies.
Authors: Sofia I Jacobson, Alec Kacew, Randall W. Knoebel, Po-Hung Hsieh, Mark J. Ratain, Garth William Strohbehn
Journal: Journal of Clinical Oncology (2022)

44 Background: Climate change from human activity results in catastrophic environmental effects that endanger human life. Health care is responsible for ̃10% of greenhouse gas emissions in the United States, thus health systems are pursuing net-zero emissions care. Methods: This single-center, retrospective, case-control study evaluated the environmental impact of alternative trastuzumab, specifically reducing adjuvant therapy duration from 12 to 6 months (in line with clinical trial evidence) and changing administration frequency from every 3 to every 4 weeks (based on pharmacokinetic simulation). Carbon emissions were estimated from round-trip travel distances, and non-biodegradable waste was estimated by collecting and weighing all single-use items used in trastuzumab preparation and administration. We generated population estimates using SEER data. Results: We identified 192 patients with HER2+ breast cancer who received trastuzumab between 2017 and 2019. At a population level, the environmental impact of continued standard-of-care dosing was 22,919 kg of waste and 1,077,210 kg of carbon emissions, requiring ̃49,000 trees to offset. 12 versus 6 months adjuvant treatment duration led to larger expected environmental benefits: 50,536 kg of waste and 3,265,039 kg of carbon emissions could be avoided with universal adoption of 6-month adjuvant therapy. Conclusions: Given health care's increasing emphasis on net-zero care, clinical trials and use of pharmcokinetically equivalent alternative dosing strategies can in part justified by environmental benefits.[Table: see text][Table: see text]
There’s no place like home: Home time among older adults with AML by therapy intensity.
Authors: Christopher Edward Jensen, Hillary M Heiling, Konan E Beke, Allison Mary Deal, Ashley Leak Bryant, Lorinda A Coombs, Matthew Charles Foster, Daniel R. Richardson
Journal: Journal of Clinical Oncology (2022)

376 Background: Older adults with acute myeloid leukemia (AML) have identified home time (HT) as a critical outcome influencing their treatment selection. However, few studies have characterized HT in this disease setting. Methods: We conducted a retrospective, observational study of adults age ≥60 diagnosed with AML from 2015 to 2020 at University of North Carolina Health. First-line therapy was classified by intensity: low (hypomethylating agent [HMA]), intermediate (HMA+Venetoclax), and high (anthracycline-based). The primary outcome was cumulative HT days from time of diagnosis. A day was defined as HT if an individual was not hospitalized and did not utilize emergency department services or ambulatory oncology clinics. Secondary outcomes were proportion of days at home (PDH) and overall survival (OS). Covariates included demographics and disease risk by ELN 2017 criteria. HT was evaluated via summary statistics with comparisons among treatment groups made via linear (for HT / PDH) or Cox proportional hazard (for OS) regression models adjusted for age &amp; ELN risk. PDH was further adjusted for log of follow up time. Median OS was calculated via the Kaplan-Meier method. Results: 197 individuals were identified. Mean age was 71 (range 60-95), 79% were white, and 59% male. 38% received high-intensity therapy, 33% received low, and 29% intermediate. Mean age was lower in the high-intensity group (66 vs 74 in low, 75 in intermediate; Kruskal-Wallis p &lt; 0.0001). Mean HT was 284 days, and median survival was 10.3 months (95% CI 8.4-12.7). Mean HT was greater in the high-intensity group at 409 days (CI 310-508) vs. 243 (158-328) in low and 169 (121-216) in the intermediate group (Table). The high-intensity group had greater median OS at 19.9 months vs. 8.8 (low) or 7.7 (intermediate) but a lower mean adjusted PDH (high: 0.60 vs. low: 0.73 vs. intermediate: 0.75; p &lt; 0.0001). In adjusted models, these differences remained statistically significant. Mean HT, median OS, and mean adjusted PDH did not differ significantly between the low &amp; intermediate groups. Conclusions: Older adults with AML spend a tremendous amount of time - roughly 40% of days - engaged in oncology care. Although receiving high-intensity therapy was associated with longer OS, increases in HT were more modest, indicating that much of the survival gains were spent engaged in care. Shared treatment decision-making should incorporate patient preferences for securing HT versus attempting to prolong survival.[Table: see text]
The impact of seasonality with hierarchical condition category coding on Oncology Care Model performance for the U.S. Oncology Network.
Authors: Jennifer Xiong, Puneeth Indurlal, Hope Ives, Judi Payne-De Bock, Chad Adams, Ramzi Abujamra, Brian Turnwald, Stuart Staggs, Jason Altieri, Rajini Manjunath
Journal: Journal of Clinical Oncology (2022)

66 Background: The Oncology Care Model (OCM) is a 6-month, episode-based, Medicare value-based care program, which rewards practices for decreasing the total cost of care (TCOC) compared to a trend adjusted predicted baseline called the benchmark price. The predicted baseline and trend factor are a function of 14 covariates in a generalized linear model with a log link and gamma distribution. Select non-cancer comorbidities, represented by a subset of Hierarchical Condition Category (HCC) flags assigned to the episode in the calendar year when the episode initiates, is a major covariate of the linear model. Patient episodes with one or more HCC flags are expected to have higher episode expenditures and receive a higher adjustment to the benchmark. Here, we seek to describe the seasonality of HCC flags and its impact on the benchmark for OCM episodes in The US Oncology Network (The Network). Methods: All eligible OCM episodes data from 14 practices in The Network participating in the OCM for performance periods (PP) 3-9 were analyzed to measure the average number of HCC flags per episode. The relative contribution of HCC flags to the benchmark was calculated by unraveling the linear model. The difference of the average HCC flags, benchmark, and relative contribution of HCC flags to the benchmark for episodes starting in different quarters of the calendar year were evaluated. Results: Average HCC flags for episodes showed a seasonal decline during each calendar year, with episodes initiating during the first quarter of a calendar year having 16.25% higher HCC flags, compared to those in the last quarter (1.93 vs 1.66 flags). The benchmark and the relative contribution of the HCC flags to the episode benchmark were lower in the last quarter of the year (4% and 16.5% respectively) compared to the first quarter. Episode expenditures did not show a similar seasonality pattern. Conclusions: The assignment of HCC flags based on the episode initiation date, leads to a seasonality effect on the average HCC flags and benchmark for episodes initiating in different parts of the calendar year. The seasonality results from a progressively abbreviated period available to assign HCC flags for episodes initiating later in the calendar year. We also hypothesize that the annual reporting requirement for HCC flags, and risk adjustment coding by professionals at the start of each new calendar year, contributes to this seasonality. The financial impact of seasonality on episodic value-based care model benchmarks necessitates a modified, non-seasonal approach to comorbidity-based risk adjustment.
Recent telehealth grant funding trends at the National Cancer Institute: A portfolio analysis.
Authors: Roxanne E. Jensen, Rebecca Hardesty, Priyanga Tuovinen, Robin C. Vanderpool, Anna Gaysynsky, Paul B. Jacobsen
Journal: Journal of Clinical Oncology (2022)

388 Background: The onset of the COVID-19 pandemic prompted a dramatic increase in the use of telehealth as health systems sought to limit patient exposure to the novel coronavirus. Positive changes in patient-provider synchronous telehealth reimbursement and regulatory policies removed long-standing barriers to telehealth uptake. Recognizing telehealth will remain an integral part of healthcare delivery, staff at the National Cancer Institute (NCI) conducted a grant portfolio analysis to assess current telehealth-related research gaps and opportunities. The goal was to examine 5-year funding trends for grants that evaluate synchronous patient-provider forms of telehealth. Methods: An initial search using NIH tools (QVR and iSearch) identified all research type grants funded by NCI between fiscal years (FY) 2016 and 2021 listing telehealth (and related terms, e.g., telemedicine) within grant titles, abstracts, and specific aims yielded 76 funded applications. Grants were excluded if they did not use synchronous telehealth, were not between a patient and provider, or were not healthcare delivery oriented. We abstracted structured variables for the final grant set (n = 45) including cancer site, stage of the cancer control continuum, patient population(s), and telehealth features. Results: A substantially greater number of telehealth grants were funded in FY20 (n = 15) and FY21 (n = 14) compared to preceding years (mean: 4 per year). The majority (75%) were investigator initiated. Breast (33%), lung (20%), colorectal (15%), and hematological (17%) cancers were most frequently studied. Over 75% of grants focused on active treatment and survivorship populations. Telehealth was most frequently used to deliver psychosocial care (35%), supportive/palliative care (35%), and/or patient self-management support and education (31%). Since 2020, grants were more likely to focus on minority populations (55% vs. 25%. p = 0.05), specify smartphone app integration (38% vs. 19%, p = 0.13), and propose integration with asynchronous data (13% vs. 0%, p = 0.30) versus grants funded from 2016-2019. Conclusions: NCI-funded grants incorporating patient-provider synchronous telehealth have increased since FY20. There are promising indications of increased focus on vulnerable populations and issues surrounding ‘digital divide’ barriers. Gaps remain within the cancer care continuum, particularly cancer screening and end-of-life when telehealth could increase access to care, with minimal patient burden. Results point to promising areas for future research and may inform efforts to advance knowledge regarding the optimal use of telehealth in cancer care delivery.
Physician referral patterns and use of adjuvant therapy among patients with stage IB-IIIA non–small cell lung cancer (NSCLC) (2010-2017).
Authors: Hrishikesh Kale, Wei-Jhih Wang, Viktor Chirikov, Anne Shah, Jon Apple
Journal: Journal of Clinical Oncology (2022)

114 Background: As the treatment landscape for early-stage NSCLC continues to evolve with the recent approvals of targeted and immunotherapy agents in the adjuvant setting, it is important to understand physician referral patterns and predictors of adjuvant therapy (AT). This study examined physician referral patterns at key treatment phases and assessed predictors of receiving AT in stages IB-IIIA NSCLC patients. Methods: A retrospective study using the linked SEER-Medicare database (01/01/2010-12/31/2017) included patients newly diagnosed with stages IB-IIIA NSCLC who received surgical resection. Specialties were identified by linking NSCLC claims to AMA Physician Masterfile. AT was defined as the use of systemic chemotherapy or radiation therapy within 4 months of surgery. Multivariable logistic regression was conducted to assess predictors of receiving AT. Results: A total of 7,108 patients met study criteria (53% IB; 9% IIA; 19% IIB; 20% IIIA). Primary care physician (PCP) (71%), surgical oncologist (29%), medical oncologist (36%) were the most frequently visited first specialist during pre-diagnosis, diagnosis to surgery, and post-surgery phases, respectively. The median time from diagnosis to surgery was 44 days. After surgery, 74% patients visited medical oncologist (62% IB; 87% IIA; 83% IIB; 88% IIIA). About 41% received AT (21% IB; 64% IIA; 56% IIB; 69% IIIA). Of those, the median time from surgery to adjuvant therapy was 46 days. Later stage at diagnosis and shorter referral time to medical oncologist significantly increased the odds of receiving AT (Table). Conclusions: The strongest predictors of receiving adjuvant therapy were time to medical oncologist post-surgery and stage at diagnosis. Future studies in the era of targeted therapies can use our results as a benchmark to optimize management and outcomes as well as assess changes in referral patterns in IB-IIIA NSCLC patients.[Table: see text]
Barriers to cancer prevention among women experiencing homelessness who receive onsite mammography, patient navigation, and education (HOPE).
Authors: Heather McKee Hurwitz, NaSheema Anderson, Kate McCaffrey, Pamela Combs, Raymond D. Jackson, Sarah S Kilic, Markayla Mariner, Tiffany Onger, Kimberly Sanders, Tyler Stimpert, Jeremy Suwarna, Jeremy Weleff, Chirag S. Shah
Journal: Journal of Clinical Oncology (2022)

111 Background: While incidence rates of cancer are lower among women experiencing homelessness (WEH), cancer mortality remains higher. Barriers to screening include economic, transportation, housing, childcare and other barriers. This study evaluates barriers to mammographic screening as part of a prospective program that provides onsite mammography services to WEH. Methods: Cleveland Clinic partnered with shelters to provide breast health education, patient navigation, and mobile mammograms onsite at shelters. Also, participants received a meal, a bra, and hygiene items. 75 women and persons of other genders completed a mammogram. 55 WEH participated in the study by completing a survey for a response rate of 73.3%. The survey included questions about barriers and demographics. We conducted a preliminary analysis to improve study quality and plan for a follow up study. Results: Participants were 40-75 years old and identified as American Indian/Alaska Native (5.5%), Black/African American (60%), and White (40%). 16% of participants received their first ever mammogram. 34% noted a family history of breast cancer and 22% had previously been advised to return for additional imaging. One participant was a breast cancer survivor. On average, participants’ last mammogram was four years prior with the greatest screening lapse being 18 years prior. A majority (n = 39, 70.9%) disagreed or strongly disagreed with the statement, “I’m afraid the mammogram will be painful.” Likewise, a majority (n = 46, 83.7%) disagreed or strongly disagreed with the statement, “I’m embarrassed about having a mammogram.” A majority (n = 44, 80.0%) also disagreed or strongly disagreed with the statement, “I’m busy and do not have time.” Almost all participants (n = 51, 96.2%) responded “yes” to the statement, “I believe in preventative care screenings.” However, participants’ responses to the statement, “I’m afraid of finding breast cancer” varied widely from strongly disagree (n = 7, 13.0%) and disagree (n = 10, 18.5%), to neutral (n = 15, 27.8%), to agree (n = 12, 22.2%) and strongly agree (n = 10, 18.5%). Conclusions: Our preliminary data shows that most participants believe in preventative screening, showing that novel services such as onsite mammography may address the lack of screening in this population. 40.7% of participants stated they are afraid of finding breast cancer, indicating this is a barrier to screening in the WEH population. Future research should explore reasons for fear (financial burden, mortality, lack of access to care, etc.) and why this may result in a lack of screening.
Optimizing outpatient oncology consult workflow using time-driven activity-based costing: Efficiency and financial impacts.
Authors: Julius Weng, Shane Mesko, Prajnan Das, Gregory Chronowski, Percy Lee, Seungtaek Choi, Albert C. Koong, Katy E. French, Thomas A. Aloia, Richard A. Ehlers, Dorothy Elrod-Joplin, Ashley Kerr, Regina Smith, Wendi Martinez, Shalin J. Shah, Matthew S. Ning, Joseph M. Herman, Shalini Moningi, Amy Catherine Moreno, Quynh Nguyen
Journal: Journal of Clinical Oncology (2022)

9 Background: Clinical efficiency is a key component of value-based healthcare, patient satisfaction, staff burnout, and institutional operational capacity. The objective of this study was to identify clinic inefficiencies using time driven activity-based costing (TDABC) and evaluate the implementation of a new clinical workflow in high volume, outpatient radiation oncology clinics. Methods: We conducted an IRB-approved quality improvement study in the Gastrointestinal (GI), Genitourinary (GU), and Thoracic Radiation (TRO) Oncology departments at a large academic cancer center and four additional network sites (HALs). TDABC methodology was used to create process maps and optimize consult workflow. Patient encounter metrics were captured utilizing a real-time status function in the electronic medical record (Epic Systems). Anonymous patient satisfaction telephone surveys were administered to patients at the HALs. Hourly wages were determined based on 2021 U.S. Bureau of Labor Statistics. Pre- vs post-implementation metrics were compared using the Mann-Whitney U test. Results: Consult data for 1328 patients pre-intervention and 1234 post-intervention across all sections was included. Median overall cycle time was reduced by 21% in GI (19 min, p &lt; 0.001), 18% in GU (16 min, p &lt; 0.001), and 12% in HALs (9 min, p &lt; 0.001). The median interval between rooming and being seen by the attending physician decreased by 13% in GI (7 min, p &lt; 0.001), 16% in GU (9 min, p &lt; 0.001), 21% in TRO (10 min, p &lt; 0.001), and 9% in HALS (4 min, p &lt; 0.005). For each consult, there was a median financial savings of $29 for GI, $24 for GU, $5 for TRO, and $14 for HALs per consult. From patient satisfaction surveys (95/177), 99% of patients reported their providers spent adequate time with them, 85% reported their appointment began on time, and 91% reported being seen by a care provider in a timely manner. Conclusions: TDABC is a successful method to identify opportunities to improve clinical efficiency. Implementing workflow changes based upon these findings led to substantial reduction in overall encounter cycle times and patient wait times across multiple departments. Furthermore, patient satisfaction was high and there were significant financial savings with the new workflow. These findings may also have implications for reducing staff burnout and expanding clinical capacity across the magnitude of clinical enterprise.[Table: see text]
The painting of a patient: Provider representations of patient fitness and preferences in multi-disciplinary tumor board meetings.
Authors: Nicole Henderson, Courtney J. Andrews, Cameron Pywell, Lisa Zubkoff, J. Bart Rose, Grant Richard Williams, Gabrielle Betty Rocque
Journal: Journal of Clinical Oncology (2022)

246 Background: Pancreatic cancer treatment can involve multiple treatment modalities (e.g. chemotherapy, surgery, radiation) that vary greatly in intensity and timing. The most intense treatments are associated with substantial toxicity and only recommended for medically ‘fit’ patients regardless of age. Despite evidence-based guidelines demonstrating the benefit of including the geriatric assessment (GA) and patient preferences, these may not be formally included in multidisciplinary tumor boards (MDTBs) where treatment decisions are often made. Methods: This qualitative study evaluated MDTB meetings at a single institution between November 2021 and February 2022 for inclusion of fitness and patient preferences. Discussions of patients with stage I-IV pancreatic cancer were identified for inclusion. These recordings were transcribed and analyzed using NVivo for recurring themes and exemplary quotes regarding how providers characterize patients’ fitness and present their preferences to the board. Results: Thirteen MDTB meetings including 50 individuals with stage I-IV pancreatic cancer were included. Descriptions of patient fitness largely consisted of the presentation of common demographic traits such as age and gender. Additional context, primarily focused on occupation, comorbidities, and patient attitudes, was provided when demographic information did not align with perceived fitness level; for example “He’s 60 years old. He’s actually very strong. He used to, or he does, work in landscaping”. There was no formal inclusion of GA data. Explicit references to patient preferences or agentive decision-making only occurred in 19 cases; 11 referring to the patient’s (non-)interest in clinical trials, 3 denying additional testing (tone suggesting non-compliance), and 7 specifically referring to treatment type preference (e.g. surgery vs. chemotherapy). Conclusions: At present, MDTB treatment discussions primarily rely on shared understandings of the cultural significance and meaning of various demographic traits and rarely reference patient-reported preferences or fitness when determining the best pathway for patient care. Further work is needed to understand how to better formally incorporate fitness and preferences into decision-making.